Management of Diabetes Mellitus in the Hospital Part 2 Kathleen Dungan, MD Assistant Professor, Division of Endocrinology, Diabetes and Metabolism

Objectives Describe the pathophysiology and clinical significance of “stress hyperglycemia”. Identify patients that require IV insulin. Explain the difference between DKA and HNK. Describe the initial therapy for DKA. Understand how and when to discontinue IV insulin. Be able to calculate daily adjustments in insulin dose. Describe the pathophysiology and clinical significance of “stress hyperglycemia”. Identify patients that require IV insulin. Explain the difference between DKA and HNK. Describe the initial therapy for DKA. Understand how and when to discontinue IV insulin. Be able to calculate daily adjustments in insulin dose.

Case 3: Post-Op Hyperglycemia 68 YOM with 20 year h/o T2DM is scheduled for elective cardiac catheterization due to abnormal stress test. Home medications: Glargine 54 units QHS, Metformin 1000 mg BID, Glipizide 10 mg BID Last A1c 7.5% 68 YOM with 20 year h/o T2DM is scheduled for elective cardiac catheterization due to abnormal stress test. Home medications: Glargine 54 units QHS, Metformin 1000 mg BID, Glipizide 10 mg BID Last A1c 7.5%

Post-op Quiz

Patient getting a procedure In general, DO NOT hold basal insulin May reduce 20-50% so that it accounts for 50% or less of the total daily dose Premix insulin : reduce 50% But, do hold meal insulin *Under no circumstances should you completely withhold basal insulin from a patient with type 1 diabetes! In general, DO NOT hold basal insulin May reduce 20-50% Premix insulin : reduce 50% But, do hold meal insulin *Under no circumstances should you completely withhold basal insulin from a patient with type 1 diabetes!

Case 3: Post-op Hyperglycemia The patient is sent for CABG. Intra-operatively, an insulin drip is started. Post-op Day 1 Extubated, pressors still running Insulin drip running at 1-6 unit/hour , BG 100s-200s Taking sips of fluids, ADA diet ordered The patient is sent for CABG. Intra-operatively, an insulin drip is started. Post-op Day 1 Extubated, pressors still running Insulin drip running at 1-6 unit/hour , BG 100s-200s Taking sips of fluids, ADA diet ordered

Transition to SQ Quiz

Predictors of Successful Cessation of Insulin Drip Our patient On drip at least 24 hours Yes DKA is resolved NA Hemodynamically stable No Extubated Minimal rate (<4 unit/hr) and minimal changes for at least 6 hrs BG controlled <150 mg/dl Tolerating PO intake CHART: Predictors of Successful Cessation of Insulin Drip Am J Cardiol. 2006;98(4):557-64.

Case 3: Converting off the drip Day 3: Patient is off pressors, afebrile Insulin drip running at 2 units/hr and stable. BG 100-130s Receiving Lispro SQ 1 unit/10 gm CHO Day 3: Patient is off pressors, afebrile Insulin drip running at 2 units/hr and stable. BG 100-130s Receiving Lispro SQ 1 unit/10 gm CHO

Convert to SQ Quiz

Does the patient need basal insulin? Yes DKA or type 1 diabetes Requiring >1 unit/hour If not… Check BG frequently once drip is stopped Patient may need meal coverage or oral med Yes DKA or type 1 diabetes Requiring >1 unit/hour If not… Check BG frequently once drip is stopped Patient may need meal coverage or oral med

Conversion to SQ insulin Basal insulin dose = 70% of total infusion requirements Assumes that the drip is not being used for meal coverage Compare to home dose of insulin Continue IV insulin/IVF for 4-6 hours after the dose Basal insulin dose = 70-80% of total infusion requirements Assumes that the drip is not being used for meal coverage Compare to home dose of insulin Continue IV insulin/IVF for 4-6 hours after the dose

Physiologic Insulin Regimen Bolus Insulin = prandial + correction dose 50 Insulin (µU/mL) 25 Basal Insulin Breakfast Lunch Dinner 150 Glucose (mg/dL) 100 Prandial Glucose IMAGE: Physiologic Insulin Regimen 50 Basal Glucose 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 A.M. P.M. Time of Day

Physiologic Insulin Regimen 3 components Examples Basal Long-acting insulin analogue NPH Continuous SQ rapid acting insulin analogue (pump) IV insulin drip Prandial Rapid-acting insulin analogue Regular insulin (tube feeds) Correction (supplemental) Prandial insulin above CHART: Physiologic Insulin Regimen BOLUS Rapid acting insulin analogues: Aspart (Novolog), Lispro (Humalog), Glulisine (Apidra); Long acting insulin analogues: glargine (Lantus), detemir (levemir)

Mooradian, A. D. et. al. Ann Intern Med 2006;145:125-134 Insulin: The most effective therapy for hyperglycemia. Insulin Preparations Onset of Action Peak Action Duration of Action BOLUS INSULIN Regular 30 minutes 2-4 hours 6-10 hours Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) 5-15 minutes 1-2 hours 4-6 hours BASAL INSULIN NPH 4-8 hours 10-20 hours Glargine (Lantus) Flat ~ 24 hours Detemir (Levemir) ? ~ 24 hours* CHART: Insulin: The most effective therapy for hperglycemia *Detemir lasts 24 hours in most patients but is slightly shorter in duration than glargine. Mooradian, A. D. et. al. Ann Intern Med 2006;145:125-134

Steps to initiating SQ insulin 1. Calculate total daily insulin dose= 0.4-0.5 unit/kg or based on insulin drip requirement 2. Basal = 50% of total daily dose 3. Prandial dose: 50% of total daily dose divided over meals I:CHO High=1u/5gm, Standard =1 u/10gm, Low=1 u/15 gm Steps to initiat Calculate total daily insulin dose= 0.4-0.5 unit/kg or based on insulin drip requirementing SQ Insulin 2. Basal = 50% of total daily dose 3. Prandial dose: 50% of total daily dose divided over meals I:CHO High=1u/5gm, Standard =1 u/10gm, Low=1 u/15 gm 4. Add correction dose (drop in BG/unit): High=1 unit/25 mg/dl above target, Standard=1unit/50 mg/dl, Low=1 unit/100 mg/dl Target (when you start giving it)=default is 150 mg/dl 4. Add correction dose (drop in BG/unit): High=1 unit/25 mg/dl above target, Standard=1unit/50 mg/dl, Low=1 unit/100 mg/dl Target (when you start giving it)=default is 150 mg/dl

“Sliding Scale” Monotherapy Without basal insulin, results in Hyperglycemia Hypoglycemia (possibly) Iatrogenic DKA with Type 1 diabetes Use of “Sliding Scale” Insulin Alone Is Discouraged Traditional sliding scale insulin Use of “sliding scale” insulin (regimens usually consist of regular insulin without any intermediate or long-acting insulin) is discouraged; evidence does not support this technique because it has resulted in unacceptably high rates of hyperglycemia, hypoglycemia, and iatrogenic diabetic ketoacidosis in hospitalized patients. Plus, “Sliding Scale” is anti-intellectual: Reactionary rather than anticipatory American Association of Clinical Endocrinologists. Available at: http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.

Measure FSG  give insulin What is a sliding scale? Measure FSG  give insulin (usually qac+hs) Standard Dose Algorithm Individualized Dose Algorithm Premeal BG Additional Insulin 150-199 1 unit ___ units 200-249 2 units __ units 250-299 3 units 300-349 4 units >349 5 units > 349 CHART: What is a sliding scale? Measure FSG  give insulin

Why not sliding scale? “Typical sliding scale” “The better way” Blood sugar before lunch 280 Blood sugar before lunch 280 Patient receives 6 U insulin sliding scale (correction factor), PLUS 5 U insulin for 75 g carb lunch Patient receives 6 U insulin sliding scale, but then eats 75 g carb lunch! Typical Sliding Scale Blood sugar before lunch 280 Patient receives 6 U insulin sliding scale, but then eats 75 g carb lunch Blood sugar before dinner 245! The better way Patient receives 6 U insulin sliding scale/correction factor PLUS 5 U insulin for 75g carb lunch Blood sugar before dinner 124!! Blood sugar before dinner 245!! Blood sugar before dinner 124!!

Dose-finding strategy Determine yesterday’s total insulin dose actually administered Address hypoglycemia first Adjust at least 10-20% based on the glucose Determine yesterday’s total insulin dose actually administered Address hypoglycemia first Adjust at least 10-20% based on the g 20

Oral Agents in the Hospital Often contraindicated Slower onset of action In some circumstances, patients can continue orals, with the following important caveats Short hospital stay Acceptable glycemic control Meformin  probably contraindicated (risk of lactic acidosis) Creatinine >1.4-1.5 IV contrast Symptomatic heart failure Respiratory failure Hepatic failure TZDs (Glitazones)  contraindicated in CHF, very slow onset Sulfonylureas  Risk of hypoglycemia Often contraindicated Slower onset of action In some circumstances, patients can continue orals, with the following important caveats Short hospital stay Acceptable glycemic control Meformin  probably contraindicated (risk of lactic acidosis) Creatinine >1.4-1.5 IV contrast Symptomatic heart failure Respiratory failure Hepatic failure TZDs (Glitazones)  contraindicated in CHF, very slow onset Sulfonylureas  Risk of hypoglycemia

Treatment of Hypoglycemia Do not overtreat! PO route preferred 10-20 gms IV dextrose 12.5 gms (1/2 amp D50)-full 25 gm Double current dextrose infusion Glucagon if no IV Do not overtreat! PO route preferred 10-20 gms IV dextrose 12.5 gms (1/2 amp D50)-full 25 gm Double current dextrose infusion Glucagon if no IV

Iatrogenic hypoglycemia is usually predictable and preventable Iatrogenic hypoglycemia is usually predictable and preventable. (Fischer) PIE CHART: Iatrogenic hypoglycemia is usually predictable and preventable (Fischer) Blue: Decreased intake of calories Lt. Green: Adjustment of insulin dosage Dk Green: Incorrect dose of insulin given Gray: No cause identified Reduce insulin, increase monitoring if - Any form of carbohydrate is interrupted - Declining renal or hepatic function Reduce insulin, increase monitoring if Any form of carbohydrate is interrupted Declining renal or hepatic function

In summary Management of diabetes in the hospital is aimed at achieving a nearly normal blood sugar Think!! Good BS management is possible in most patients with some careful consideration Diabetes consult team is available for help (at least at OSU) Management of diabetes in the hospital is aimed at achieving a nearly normal blood sugar Think!! Good BS management is possible in most patients with some careful consideration Diabetes consult team is available for help (at least at OSU)

Please direct questions to: [kathleen.dungan@osumc.edu]

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